Enrollment Agreement

When enrolling as a client Spencer Psychology, you agree to the following:

Consent for Treatment

I agree and consent for myself (or my minor child) to participate in the mental health services or evaluation offered by the staff of Spencer Psychology.

I understand that I am consenting and agreeing only to those mental health services or evaluation that the provider is qualified to provide within the scope of the provider’s license, certification, and training.

Confidentiality

In general, the privacy of all communications between a client and a mental health provider is protected by law. Information can only be released with your permission. There are exceptions to this:

There are some situations in which a provider is legally obligated to take action to protect others from harm, and confidential information about you can be released. For example, if there is information that a child, elderly person, or disabled person is being abused or neglected, a report is made with the appropriate state agency.

If a client is threatening serious bodily harm to another, protective action must be taken. These actions may include notifying the potential victim (a “duty to warn”), contacting the police, or seeking hospitalization for the client. If the client threatens to harm himself/herself, or through significant mental health symptoms is at risk to harm himself/herself, the provider may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection.

In most legal proceedings, the client has the right to prevent the provider from releasing information about treatment. However, if the provider receives a court order from a judge (not just a subpoena from an attorney), the records or information must be released. In some proceedings involving child custody or CHINS cases, and those in which the client’s emotional condition is an important issue, a judge may also order testimony in court if the judge determines that the issues demand it.

Recording

We do not allow recordings of sessions, as recordings can jeopardize confidentiality and trust. If we learn you have recorded a session, posted a recording on social media, or used a recording in any way, we may opt to discontinue your services.

Internal Consultation

Therapists at Spencer Psychology are all part of the same practice, and may share treatment information internally with another of our therapists for the purpose of consultation, supervision or coordination if needed for your case. This could include second opinions on treatment options,  diagnoses, or seeking suggestions to improve their delivery of your care.  If you have Medicaid, Medicare or Healthy Indiana Plans (HIP), these payers require that one of our psychologists review your treatment plan on a regular basis.

If you and your partner/spouse/child/family member are both clients at the practice, your individual therapists may consult about shared family dynamics or crises. If you do not want this consultation, please let your therapist know.

No Show/Late Cancellation Policy

• If you need to cancel your appointment, please allow 24 hours notice. This will allow your provider to reschedule your slot with another client from the waiting list.

• If timely notice is not given, or if clients fail to show for the appointment, a fee of $75 is assessed. Insurance does not cover the fee. You may be required to pay your fee before you may reschedule.

• If you have scheduled a specialty service that is longer than an hour (such as EMDR or couples counseling), a no-show/late cancel fee of $100 is assessed due to the longer time frame reserved for you.

Email, Cell Phone, Social Media and Fax

Please notify the provider if you decide to avoid or limit, in any way, the use of any or all communication devices, such as email, cell-phone or faxes.

Email: If you choose to communicate by email, be aware that all emails are retained in the logs of the Internet service providers on both your end and the providers' end. While it is unlikely that someone will be looking at these logs, they are, in theory, available to be read by the system administrator(s) of the Internet service provider. You should also know that any emails received from you and any responses that are sent by the provider can be retained as part of your clinical chart. All email exchanges can be subpoenaed in a court proceeding.

Texting: Please limit texting contacts to scheduling issues, or to request a phone call if there is an issue that needs our attention. We cannot effectively manage counseling issues by text. You may use our texting service to ask billing questions or to schedule. This will go to our support staff (not your therapist).  The number is (866) 222-1629.

Social Media:  To protect privacy, we cannot accept friend requests on social media sites.

Crisis Issues

After-Hours Care/Hospitalizations:  Our practice is not designed for clients who frequently need crisis care, and we do not have clinicians on-call. If you have already been hospitalized frequently or have issues with frequent suicidal thoughts or behaviors, please discuss this with the therapist during your initial session so that we can determine if our practice is an appropriate match for your needs.

If you do need to be hospitalized, or if you need after hours crisis care, insurance will not cover the clinician’s time tending to this issue. This time is billed at a self-pay rate of $150 per hour (it is prorated if there is less than an hour spent).

Non-covered Services Policy

Case Management Requests: If you request additional services outside of therapy sessions (such as crisis services over the phone, or reports to outside parties), these services are not a benefit of your health insurance coverage and will be charged out of pocket. Routine coordination, such as updates to your family doctor, are not charged.

Court Services: Court services are billed at $175 per hour for all clinicians. This includes writing reports, preparation time for hearings, meeting with the attorney, waiting time at court and testimony. If the hearing is outside of Monroe County, travel time is also billed at $175 per hour. If there is more than one party to the court hearing/trial, the court fees will be paid by whichever party has sent the subpoena. A retainer will be taken for any non-covered service request.

A retainer is also required at least one week prior to any court appearance. An itemized statement will be provided after the service has been completed, and any underestimate of the fee will then be charged. If the retainer has overestimated the time needed, a refund will be issued.

Insurance/Billing

I authorize the release of any medical or other information necessary to process payments for insurance claims, as well as information necessary to process delinquent accounts with an attorney, small claims court or collection agency. If I have made arrangements with a parent or other party to pay my bill, I give permission for communication related to the bill to occur with the other party. This may include the other party seeing an invoice of my services, which includes diagnosis code and dates of services.

Secondary Insurance: We do not file claims for secondary insurance. All deductible payments and co-payments for your primary insurance are still due at the time of service. Occasionally, primary insurance will send the claim on to your secondary carrier automatically. If we receive an automatic payment, you will be refunded the amount we received. If you wish to file secondary insurance yourself, we can supply you with an invoice for your services to submit to your secondary carrier. If this processes correctly, your secondary insurance should send the payment directly to you. If the claim is denied, Spencer Psychology is not responsible for follow up. Medicaid plans do not allow you to file the insurance yourself at all. If your secondary insurance is through Medicaid, we cannot see you.

I have read the above and understand.

Client Name:
 
Electronic Signature of Client/Parent/Guardian:
 
Date: